Medical History, Supplement No. 1, 1981: 19-44 FEVER PATHOLOGY IN THE SIXTEENTH CENTURY: TRADITION AND INNOVATION by IAIN M. LONIE* INTRODUCTION THIS PAPER is offered as a preliminary survey of mainstream writing about the pathology of fever in the sixteenth century. It is selective in the writers discussed, and confined to three topics: the definition of fever and febrile heat, the explanation of intermittent fevers, and the role of putrefaction.' The paper is partly concerned with the relation between tradition and innovation. From this point of view, the writers discussed under the three topics listed above have their places along a descending scale of orthodoxy. Both in form and content, sixteenth-century discussion of fever tends to be a prolongation of medieval discussion. It is not characterized by any notable rejection of the authority either of Avicenna or of Galen, nor by any significant tendency to apply new observation to traditional theories. As might be expected,2 the sixteenth century presents a picture of pathology rather different from the one which it presents in anatomy. Radical new approaches to the topic of fever did not occur until the follow- ing century, when they were prompted partly by the development of Paracelsian ideas, and partly by Harvey's discovery of the circulation.3 On the other hand, these changes in approach were not without anticipation in the sixteenth century, as the examples of Jean Fernel and Gomez Pereira will show. Of these two men, the one rejected the scholastic tradition, and the other vigorously defended it; but neither can be understood without an appreciation of that tradition. In fever literature it appears as a series of conventional quaestiones or problems, with approved strategies for their solution. These quaestiones had been generated, during the medieval period, by discrepancies and silences in Galen's account of fever. Most sixteenth-century writers simply followed the routine lines established by their predecessors. But the existence of such quaestiones, and the cryptic nature of Galen's account, left the traditional * lain M. Lonie, M.A., Wellcome Unit for the History of Medicine, Free School Lane, Cambridge CB2 3RF. 1 Thus it does not include taxonomy, therapy, or the discussion of pestilence. Inclusion of this last topic (where the ancient tradition was singularly unhelpful) would have given a very different picture; but it is a subject in its own right, distinct from that of fever, while the topics discussed in this paper are an indispens- able background to plague literature. 2 See 0. Temkin, Galenism, Ithaca, N.Y., and London, Cornell University Press, 1973, ch. 4, e.g. p. 152 and p. 165. I See Audrey B. Davis, Circulation physiology and medical chemistry in England 1650-1680, Kansas, Coronado Press, 1973. 19 Iain M. Lonie theory somewhat open-ended even for the most conventional, while some writers were ready to exploit this fact in novel directions. This is clearest in Fernel's discussion of intermittent fevers and in Pereira's conception of febrile heat as the effect, and not the cause, of the accelerated motion of the heart and arteries. But even with the nature of fever, where discussion tends to be most conventional, we can detect a new emphasis on the concept of innate heat, although this arises quite naturally from the tradition. The texts referred to in this survey were not written in a vacuum, but for the most part in response to pedagogical obligations. The topic of fevers was an important part of university courses in practical medicine. The prescribed text was usually the first fen of the fourth book of Avicenna's Canon, and lectures on fever most commonly took the form of a commentary upon this text, as they had in the medieval period. Avicenna might be supplemented by Galen's De febrium differentiis, and some teachers preferred to lecture on this text, with reference to Avicenna.4 Even when the course did not take the form of a commentary, as in various "Arts" or "Methods" of practical medicine, it nevertheless tended to follow Avicenna's order of topics, dealing first with the definition and essence of fever, then with the differentiation of fevers into their three main types (ephemeral, humoral, and hectic), followed by an exposition of the causes, diagnosis, and treatment of each type and sub-type. Besides these teaching texts, there were less formal genres in which fever might be discussed: collections of controversiae, paradoxa, and medical epistles. These were new genres, prompted by the invention of printing, as was the separate monograph or tract in which an individual point of view might be expressed and addressed to the indeterminate audience created by printing. Finally, there were the many collections of medical observations and consilia published during the century, in which fever cases were fre- quently included. While these often discussed theoretical matters, they generally con- firmed traditional diagnosis and traditional taxonomy: the latter provided a con- venient principle of arrangement.5 I. THE DEFINITION OF FEVER It was generally agreed by sixteenth-century writers on fever, as by their pre- decessors, that the nature of fever lay in the "heat contrary to nature" or preter- natural heat experienced by the patient. Almost all of them regarded this heat as a 4Among authors of commentaries or virtual commentaries may be mentioned Argenterio (1592); Massaria (1601); Trincavelli (1586); Valles (1569); Vega (1576). Trincavelli, lecturing on the text of Galen, assured his students that his comments were applicable to the corresponding loci in Avicenna, which they presumably had before them (p. 18). This is at Padua. Massaria, also at Padua (in 1587) lectured on the text of Avicenna, but said that since Avicenna was a more obscure author than Galen, his policy would be to explain Avicenna by reference to Galen. Argenterio, despite strictures on the uselessness of teaching by commentary, did claim to follow Avicenna's order closely (DeJebribus liber. Proen). I E.g., Foreest (1586 etc.), who arranged his observations according to the traditional classitication of fevers, linking classes with transitional types (a feature of Galen's approach to diagnosis) and he preceded each main group with an orthodox disquisition on symptoms, causes, and some discussion of quaesliones. Thus his work reads like a treatise on fevers very fully illustrated by textbook examples of each kind and variation. Since some were taken word for word from fifteenth-century writers of Practica, we may be suspicious of the originality of Foreest's observations. The same approach to arrangement was adopted by Jodocus Lommius, Medicinaliuni observationumz libri tres, Antwerp, G. Sylvius, 1560. 20 Feverpathology in the sixteenth century: tradition and innovation distinct kind or genus of heat, contrasted with other kinds. The most important of these was "innate" or "natural" heat: this was characteristic of the living animal and enabled it to perform its natural functions. Unnatural, preternatural, or febrile heat (the terms are interchangeable) was also called "extraneous" heat, i.e. extraneous or foreign to the living animal, as opposed to its own innate heat.' In the account which follows, the fundamental opposition is between febrile (preternatural, unnatural, extraneous) heat and innate (natural, animal) heat. We should recall that heat was regarded as a substance, which was capable of division into different genera and species. This view followed naturally from a cosmology which regarded heat or "the hot" as one of the four elements of which all things, both animate and inanimate, are composed. Galen had left no clear and unambiguous definition of fever. In De febrium differentiis, which assumed in the reader knowledge of much previous discussion by other writers now lost, he took the definition for granted, saying only that fever belonged in the genus of heat contrary to nature. Late Alexandrian writers, however, constructed a compendious definition out of scattered statements in Galen, and in this they were followed by the Arabs, notably by Avicenna. Avicenna's definition became the standard one for discussion: "Fever is extraneous heat, kindled in the heart, from which it is diffused to the whole body through the arteries and veins, by means of the spirit and the blood, reaching a heat in the body itself which is sufficient to injure the natural functions".7 Averroes, however, had given an alternative formulation: according to him fever was not merely extraneous heat, but must be to some extent natural or native heat, and was in fact a unity composed of natural and extraneous heat.8 This formula was modelled upon an incidental remark by Galen in his commentary upon the Aphorisms of Hippocrates: "fever occurs through the conversion of innate heat to the fiery".9 This disparity between Avicenna and Averroes set the terms for all subsequent discussion, which pivoted on the relation between the preternatural heat of fever and natural heat. The implications of this debate, and the kind of argument with which it 6calor extraneus was the standard translation of the Greek thermotes allotria ('foreign' or 'alien' heat) used both by Aristotle and Galen. This term appears to have been adopted into the discussion of fever from the Aristotelian Meteorologica 4, where it was used in the explanation of putrescence (sFpsiv). Putrescence was there defined as "the destruction of a moist body's own natural heat by heat external to it, that is, the heat of the environment.' (Meteor. 4,1. 397al7; trans. H. D. P. Lee). Since at least some fevers were supposed to be caused by putrid humours (see section III of this paper), this became a key text in medieval and Renaissance fever literature; and the term "extraneous heat" conveyed to those who used it a distinct opposition to natural heat.